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Case Conference

Case Conference. Myra Lalas PGY 2. CC: seizures. HPI: 8 Y F with no significant PMH transferred to CHAM 10 from Jacobi for status epilepticus 1/15- malaise 1/17- fever started 1/18- several episodes of NBNB emesis

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Case Conference

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  1. Case Conference Myra Lalas PGY 2

  2. CC: seizures HPI: 8 Y F with no significant PMH transferred to CHAM 10 from Jacobi for status epilepticus 1/15- malaise 1/17- fever started 1/18- several episodes of NBNB emesis 1/19- went to PMD with T= 105.3 and started on Cefprozil 500 mg BID for b/l AOM

  3. 1/21- went back to PMD for persistent fevers- switched to Augmentin • 1/22- full body shaking (2 mins) followed by confusion and fecal incontinence • On the way to Jacobi ER, had 2nd seizure episode. Given Ativan and loaded with Dilantin. • In Status- was transferred to CHAM PICU for EEG monitoring

  4. No sick contacts; no recent travel • PMH: unremarkable • Imm Hx: UTD • NKDA • FMH: no epilepsy, no asthma • P/S Hx: in 3rd grade; does well in school; lives with both parents; recently acquired 2 new vaccinated dogs

  5. Physical Exam VS T= 39.1 P 120 R 21 101/71 98% RA Gen responds to painful stimuli, nonverbal, GCS 9 HEENT PERRLA, TM’s normal b/l, clear OP, no LAD, (+) erythematous patches across cheeks Chest CTA b/l Heart N S1/S2, no murmurs Abd soft, ND, (+) BS, no HSM Ext FEP, CRT < 2 secs, (+) blister on R heel

  6. Labs • CBC H/H 10.9/33.1 Plt 137 WBC 5.2 N 29 L 32 M 30 • BMP Na 136 K 3.8 Cl 102 HCO3 21 BUN 6 Crea 0.5 Glucose 111 Ca 8.8 Mg 1.6 P 2.4 • LFT’s alb 3.3 TP 5.7 AST 89 ALT 104 alk phos 93 TB 0.2 DB 0.1 • Dilantin 14

  7. ABG pH 7.42 pCO2 37.2 pO2 200 BE -0.3 HCO3 23.6 • RSV (+) • Flu neg • HSV ½ neg • RVP neg • Cultures: Blood Culture 1/27 NG 1/31 NG

  8. Respiratory Culture 1/27 NG 1/31 NG Urine Culture 1/27 NG 1/31 NG CSF Culture 1/26 NG AFB CSF Culture 1/29 neg Wound Culture 1/25 NG

  9. ANA neg • Parvovirus B19 IgM and IgG WNL • Bartonella IgM and IgG WNL • Cryptococcal Ag serum NR IMAGING CXR no effusions of consolidations Repeat: inc LL opacity (atelectasis or consolidation) US Abd/Pelvis hepatomegaly, ascites, b/l trace pleural effusions, gallbladder sludge CT Head neg MRI neg

  10. EEG • Electrographic sz patterns, b/l independent L>R, posterior quadrant • Spikes and polyspikes, multifocal • PLED’s, generalized • Burst suppression, generalized

  11. Differentials? • Anoxic/ Ischemic Encephalopathy • Metabolic • Toxic • Systemic Infection • Vasculitis • Reye’s • Paraneoplastic • Trauma • Lupus

  12. Viral Encephalitis • Acute CNS dysfunction with radiographic or laboratory evidence of brain inflammation. • HSV encephalitis is the most common diagnosed cause of sporadic encephalitis • Majority have no etiologic identified.

  13. Causes of viral encephalitis Herpes simplex virus (HSV-1, HSV-2) Other herpes viruses: VZV, CMV, EBV, HHV6 Adenoviruses Influenza A Enteroviruses, poliovirus Measles, mumps and rubella viruses Rabies

  14. Arboviruses—for example, Japanese B encephalitis, St Louis encephalitis virus, West Nile encephalitis virus, Eastern, Western, and Venezuelan equine encephalitis virus, tick borne encephalitis viruses Bunyaviruses—for example, La Crosse strain of California virus Reoviruses—for example, Colorado tick fever virus Arenaviruses—for example, lymphocytic choriomeningitis virus

  15. HSV Encephalitis • Fever, personality change, autonomic dysfunction, dysphagia, seizures, headache • Mildly elevated WBC, lymphocyte predom, mildly elev protein • Bilateral temporal lobe involvement of CT or MRI • Dx test of choice: HSV DNA PCR of the CSF • Tx: Acyclovir 10 mg/kg per dose q8 for 2-3 wks

  16. HSV MRI findings Note left temporal lobe involvement

  17. EBV Adolescents and young adults Fever, altered mental status, headache, seizures, focal neurologic deficits Dx: EBV DNA by PCR of the CSF M. pneumoniae Fever, headache, vomiting, seizures, altered level of conciousness Dx: CSF or brain tissue PCR + culture; serology

  18. Cat- Scratch Disease B. Henselae Both CSF exam and brain imaging results usu are normal Dx: detection of antibodies in the serum Most patients recover w/o tx in 1-3 mns.

  19. Rabies 75% of children develop illness within 3 mns of exposure Fever, sore throat, chills, malaise, dyspnea, cough, paresthesia at inoculation site, paralysis, hydrophobia, delirium Fatal

  20. Acute Disseminated Encephalomyelitis • Postinfectious encephalitis • Altered level of consciousness, fever, headache, neck stiffness, CN abnormalities, ataxia • MRI: multifocal, patchy, high signal lesions on T2-weighted images (white matter > gray matter) • Inc CSF WBC but no oligoclonal bands suggestive of MS • Monophasic (vs MS) • Tx: high dose glucocorticoids

  21. ADEM MRI Bilateral asymmetric lesions with open ring enhancement characteristic of demyelination

  22. Initial Laboratory Testing Cerebrospinal Fluid ● Glucose, protein, cell count, differential count ● Routine bacterial culture ● Viral culture ● Herpes simplex virus polymerase chain reaction (PCR) ● Cryptococcal antigen ● Enteroviral PCR ● Mycoplasma PCR

  23. ● Tuberculosis culture and PCR ● Epstein-Barr virus PCR ● West Nile virus immunoglobulin (Ig) M

  24. Blood ● Bartonella henselae Ig G ● Epstein-Barr virus serology panel ● Lyme IgG (in endemic areas if cranial neuropathy present) ● Mycoplasma IgM ● West Nile virus IgM (during mosquito season) ● CBC with dc ● Serum to be saved for comparison with convalescent specimen

  25. Other ● Viral cultures of nasopharynx and stool ● PPD

  26. Course in the PICU • EEG showed status epilepticus: improved on Fosphenytoin, VPA and Levatiracetam • However, seizures recurred and pt was placed on Pentobarbital coma. • Started on Acyclovir, Ceftriaxone, and Vancomycin • Cultures negative- CFTX and Vanco stopped • Started on Moxifloxacin x 7 days to cover for intracellular atypical bacteria causing CNS disease (due to inc LL opacity and fever and concern for Mycoplasma)

  27. On week 2 of PICU stay, patient was started on IVIG (12mg/day) x 5 days • Needs convalescent mycoplasma serology, CSF state enceph panel follow up • For MRI/ MRA

  28. References Kennedy, PGE. Viral encephalitis: causes, differential diagnosis, and management. J Neuro Neurosurg Psychiatry 2004;75: i10-15. Lewis, P and C Glaser. Encephalitis. Pediatrics in Review 2005 26; 26: 353-363.

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